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Q. Kindly give your expert opinion regarding heart surgery.

Answered by
Dr. Rishu
and medically reviewed by iCliniq medical review team.
This is a premium question & answer published on Dec 17, 2016 and last reviewed on: Jan 28, 2021

Hi doctor,

My relative has got heart attack some days before. I have his reports. We need a second opinion about surgery whether he should go or not. His presenting complaint includes chest pain and high blood sugar. He is under diabetes medicine.

#

Hi,

Welcome to icliniq.com.

  • Kidney function tests of your relative are deranged (attachment removed to protect patient identity). His serum creatinine levels and potassium levels are high.
  • What do you mean by surgery? Is that open heart surgery or stenting?
  • However, the surgery can be done only kidney function tests become normal, otherwise the patient can land up in renal failure.
  • Right now ask the nephrologist to make his parameters stable (kidney). It will take about two days. Then, you can proceed with surgery.
  • Emergency surgery can be done with deranged kidney functions also, but chances to land up in acute renal failure are high.

For further information consult a cardiologist online -->https://www.icliniq.com/ask-a-doctor-online/cardiologist

Hi doctor,

He has been suggested for open heart surgery.

#

Hi,

Welcome back to icliniq.com.

I have noted all the details.

  • The patient had a massive myocardial infarction as depicted by the ECG. His left ventricle ejection fraction is critically low only 20% and his ECG is showing premature ventricular contraction, which suggests gross ischemia in the heart.
  • Whether to go for angioplasty (stenting) or open heart bypass surgery depends on a number or factors like number of coronary arteries blocked, location and site of blockages, etc.
  • Kindly attach the detailed reports of angiography as the age of the patient is 58, diabetic, renal functions are deranged and ejection fraction of heart is critically low.
  • The overall mortality rate in elderly post CABG (bypass surgery) is 3% to 4%. During the surgery itself heart attack can occur in 4% to 5% of patients, which may cause immediate mortality, and about 5% of the elderly patients require re-exploration post CABG due to bleeding complications.
  • This mortality is increased, if ejection fraction is low (only 20% and the normal value is more than 55%) or the disease involves left main coronary artery or the patient is diabetic (as in your case).
  • While complication and mortality rate, post stenting is much lower in patient with multiple morbidities, but angiography report is required before deciding whether to go for stent or bypass.
  • As you have asked for bypass only, I would consider that angiography must be showing something that has only bypass as an option and stenting is not possible. Making that as an assumption, I would like to advise you to go for minimally invasive coronary bypass surgery - MICS CABG or MICAS stands for minimally invasive coronary artery surgery.
  • It is a relatively new and advanced technique of performing coronary bypass for coronary artery disease. In this technique, the heart is approached through the side of the left chest through a small 4 cm incision. This cut is placed just under the nipple. The chest is entered between the ribs without cutting any bones and by splitting the muscle.
  • Conventional CABG or coronary bypass surgery is performed by splitting or cutting through the breastbone or sternum. MICAS is a latest advent in the field of cardiac surgeries. It is very safe and useful, especially in older patients with other chronic conditions, renal problems and patient with very low cardiac functions.
  • Advantages of MICS over conventional CABG in old age patients, especially in patients with uncontrolled diabetes with recent massive myocardial infarction are as follows.
  • All infections are reduced whether it be wound infections or post surgical lung infection. This makes the procedure ideal in diabetics and older patients who have poor resistance to infection. In fact, this is the biggest advantage in your case. The risk of infection is close to zero. All infections are reduced dramatically in MICS.
  • The blood loss is almost negligible eliminating blood transfusion in most and eliminating blood borne infection. As condition of heart in your case is very poor; hence, too much blood loss should be avoided.
  • As no bones are cut, advantages in reducing pain, retaining function and having a positive effect on breathing. Unlike traditional CABG where bones are cut and the patient has to suffer from a lot of pain for at least two weeks after the operation.
  • The patient will be discharged in four days, unlike the conventional heart surgery that takes 14 days.
  • But, I would say that I would like to see the angiography reports and if possible videos of angiography to see if stenting is possible, because in patients with multiple ailments with low EF recovery post CABG is sometimes difficult.

Revert back with the reports to a cardiologist online --> https://www.icliniq.com/ask-a-doctor-online/cardiologist

Hi doctor,

I will try to send and I have that on a CD. Which specialist should we consult?

#

Hi,

Welcome back to icliniq.com.

  • The mentioned surgery will be done by CTVS Surgeons (cardiothoracic and vascular surgeons).

Revert back with the reports to a cardiologist online --> https://www.icliniq.com/ask-a-doctor-online/cardiologist

Hello doctor,

As you have suggested we have gone and meet CTVS surgeon. He said that MICS is possible in his case, but he was not fully sure. He wanted to see the patient and then, will tell clearly. But, in another hospital, they said that it can be risky in his case. Here, the doctor said that in MICS 6% risk is there. He advised for bypass surgery. I have attached some more reports of angiography, perfusion imaging and echocardiogram report. I would like you go through those reports and suggest either MICS or bypass surgery.

#

Hi,

Welcome back to icliniq.com.

I have seen all the reports of the patients (attachment removed to protect patient identity).

  • In my opinion, the patient is not a good candidate for minimally invasive surgery. An ejection fraction of the patient is critically low, only 20% and angiogram shows all three major coronary arteries are critically narrowed.
  • This patient will require at least four to five grafts. Usually we use graft of LIMA (arterial graft), but arterial grafts are usually not successful when ejection fraction of the patient is critically low.
  • Arterial grafting through minimally invasive technique is usually done when we need one or two grafts. So, in your case venous grafts will be used. The life of a venous graft is about 5 years and venous grafting is not usually done by minimally invasive procedure.
  • The chances of recovery are good as PET scan shows a viable myocardium (blood supply is hindered, but heart muscles are still alive).
  • MICS can be done and I think the risk will be about 10% more than open heart CABG. The final decision rests with the cardiothoracic surgeon.

For further information consult a cardiologist online --> https://www.icliniq.com/ask-a-doctor-online/cardiologist

Hello doctor,

Yesterday, my uncle has got breathing problem. He was admitted in CCU. There he underwent tests for cardiac enzymes and I am attaching the reports. Please check it once. He has done treadmill some hours before he suffered breathing problem. Currently, he is in CCU. Does he require a stay in hospital or can it get cured with medicine at home?

#

Hi,

Welcome back to icliniq.com.

  • You have not mentioned whether bypass of your relative was done or not.
  • According to the reports enclosed by you (attachment removed to protect patient identity), his Trop I (troponin I) is very high. It is possible that he had a minor heart attack again.
  • Trop I is a very sensitive marker of cardiac muscle damage. Hence, most likely the breathlessness can be due to cardiac events.
  • You have not mentioned the reason for his treadmill test. Also, suggestions will be different in case he is post bypass surgery.

Revert back with the details to a cardiologist online --> https://www.icliniq.com/ask-a-doctor-online/cardiologist

Hi doctor,

He has not undergone any treadmill test. He simply went gym, did the treadmill and after which he was not feeling well. And, he has not undergone surgery yet as his creatine was 1.5. Doctor said that once it comes down below 1 we will perform. He is undergoing treatment for that. Meanwhile, yesterday he did exercise and he started feeling breathless. So, he has admitted to CCU.

#

Hi,

Welcome back to icliniq.com.

  • His angiography reports say that complete blockage of major coronary vessels. He had a heart attack recently, any type of exercise (even mild in nature) is contraindicated for him until the surgery is done.
  • You said he used treadmill, most likely he had a heart attack again because of that.
  • His troponin was elevated and his ejection fraction was just 20%. Both of them points toward him having another heart attack. Breathlessness was because of heart attack or sudden deterioration of his cardiac functions.
  • Kindly send me the ECG taken yesterday at CCU (coronary care unit) and a copy of treatment, which he was taking. I can suggest him more anti-anginal till bypass surgery is done.
  • As of now keep him in CCU till cardiologist clears him and his breathlessness settles down fully.

Revert back with the reports to a cardiologist online --> https://www.icliniq.com/ask-a-doctor-online/cardiologist


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